In this piece, spurred on by the maelstrom of events which surrounded the arrest of a surgical tech from Swedish Medical Center the previous month, Osher and Olinger point out the simple truth that hospitals do not all prescribe to the same standard of safety and precaution when a drug diversion occurs. It was made clear that simply not reporting a theft, leaves open the possibility of hiring of these drug diverting healthcare workers at other facilities and allow them to continue their diverting ways. These reporters did an extensive job in reviewing state health department, licensing board and police records. And the results were unbelievable. Read more
Several new investigations into healthcare associated transmission of bloodborne pathogens have been reported lately. Lauren recently reflected on an investigation into possible drug diversion by a surgical tech that could result in transmission of hepatitis C from the surgical tech to patients through reuse of syringes in the Denver area. A recent news article reported on a situation in which a nurse employed by an Omaha wellness company reused two syringes to administer 67 flu shots.
Of course we are horrified by these potential outbreaks, as we always are whenever there are reports of unsafe injection practices. Our hearts go out to those affected by the unsafe practices. We know the anxiety, anger and betrayal that many feel, because we have felt those same feelings ourselves when we contracted Hepatitis C through reuse of syringes and medication vials.
But what makes these reports of potential outbreaks even more difficult for us, is that they are linked to our own backyards.
Lauren lived in the Denver area for many years, and was affected by the Rose Medical Center outbreak through drug diversion in 2009. Evelyn lives in Fremont, NE forty miles from Omaha, and was one of 99 people who contracted Hepatitis C through reuse of syringes during chemotherapy in 2002.
Ever since we were harmed by unsafe injection practices, we have worked hard to educate about and advocate for injection safety. We have wept with victims, argued with policy makers, and encouraged healthcare providers, educators and administrators to do the right thing for many years now. The work is consuming, demanding, – but usually rewarding.
But when the outbreaks happen in our own backyard, we feel so many more emotions. Anger. Frustration. Discouragement.
Perhaps the most salient emotion is bewilderment. How can this be? Didn’t everyone read about our outbreak in the newspaper, or see a report on TV? Wasn’t everyone shocked and horrified? Didn’t we hear over and over again – “We can’t let this happen again!”
And yet it did. Of course changes were made – even sweeping changes – right after our outbreaks. We were gratified by the improvements that we saw implemented. But time moves on – people change jobs, memories dim, attention to safety is threatened by the demanding pace, or cost cutting, or a culture of poor communication within the healthcare team. And then reuse of medical equipment intended for one time use happens again, either intentionally or unintentionally.
And then we are back to where we were years ago – weeping with victims, arguing with policy makers, encouraging healthcare providers, educators and administrators – in some instances the very same officials we interacted with at the time of our outbreak.
At times like these we have to sit back, take a deep breath, and reflect on our advocacy. Are our efforts worthwhile? Should we continue? And almost immediately, the answer comes from deep within – “YES!”
For although we learn through the media for months about the number of people who were affected by unsafe injections in our hometowns, we do not know how many people we have saved from injury through our efforts. We know it is a great many. We know that the educational efforts of the One and Only Campaign and the advocacy efforts of the Drug Diversion Prevention Committee are making a difference. We know this whenever someone comes up to us after hearing us speak and tells us, “I’m taking your story back to my co-workers, and we are going to make some changes!” We carry those statements in our hearts, and bring them to the top of our minds at times like these.
So. Back to work. Lets all commit to making “One needle, one syringe, and only one time” happen everywhere in the world, not just in our own backyards.
News broke a few weeks ago about a possible drug diversion event in Colorado. The more we here about the details of this incident, the more we understand just why a national registry for healthcare workers is so important. Even with the current registry the state of Colorado has for surgical technologists, we see that we have still fallen short in regard to gaps in the system.
It appears the surgical tech who was caught with a syringe in an operating room where he was not scheduled has lost every previous hospital job due to drug violations. At least one other job he was caught stealing a syringe and in still another he tested positive for fetanyl. It appears 4 states are now involved in an ongoing investigation. Read more
This past week we learned that there was another incident of drug diversion at Swedish Medical Center in Englewood, Colorado. This is not far from Rose Medical Center in Denver, the site of the 2009 drug diversion event which caused 19 patients to be infected with Hepatitis C. So if this seems eerily familiar, you are right, it is.
At last report, no exposure to any infectious diseases have been reported. My sincere hope is this remains to be the truth for the almost 3000 patients who were notified that they may have been put at risk.
But the cold hard facts remain. There was another drug diversion at an HCA hospital, the same hospital system which includes Rose Medical Center. And I am sure the most asked question is going to be “Why?” Why were there not better systems put into place to safeguard again this? Why did we not learn from the mistakes made in 2009?
We ask why because we know this was a completely preventable event. We ask why because despite any reliable data about the frequency of drug diversion in healthcare facilities, primarily due to the covert nature of this crime, we know it is always a possibility, always a risk. We ask why because there are many hospital systems who have successfully been able to monitor, assess and prevent drug diversion incidents.
So while my thoughts remain with those 3000 patients and their families and friends as they await news of their blood tests, I find comfort in knowing behind the scenes the Colorado Department of Public Health and Environment is doing what needs to be done to investigate, educate and keep the risks at a minimum. With the help of the CDPHE’s One and Only Campaign, awareness is being raised among patients and healthcare providers regarding safe injection practices. Or if more information is needed, please contact HONOReform at www.honoreform.org.
Below you will find a guest commentary which appeared in the Denver Post this past Saturday offering solutions for the future.
Drug diversion, “anytime prescription drugs are obtained or used illegally,” is like climate change, in a way. In our experience, most people either do not want to believe it exists or cannot believe it exists. When you start to tell them about it, they close their ears. It’s not that they are rude or there’s a short attention span. It’s just too frightening—unexpected and baffling—too much for them to take in.
We are not in the business of creating wariness, mistrust or fear. We are simply in the business of safeguarding the medical injection process. One of the ways that drugs are diverted in healthcare systems or clinics is through improper injections.
Oftentimes—at least three times that we are aware of, three outbreaks in which multiple patients were infected with hepatitis C—an addicted, infected healthcare worker will inject medication prescribed to a patient into himself or herself, refill these vials with saline then put them reuse them.
If there’s even a speck of infected blood in that injection device, the patient who receives this injection could become infected. Also, the patient is not receiving the proper dose of prescribed medication.
When it comes to drug diversion, there are many overlapping patient safety and worker safety issues. Drug diversion has to be prevented. And, to prevent the problem, to really mobilize to prevent this problem, we need a clear, consistent and acknowledged definition of the problem.
Once again, it’s CDC to the rescue!
Just Google “CDC Drug Diversion,” and the ongoing problem is made clear. On the CDC page titled “Risks of Healthcare Associated Infections from Drug Diversion,” there are sections titled “Outbreaks,” “Prevention Resources,” “Enforcement Agencies,” and much more.
We have touted this work before, this extraordinary ongoing science and research collection, but it bears repeating, especially as we are working toward gathering for a national meeting on drug diversion prevention in early 2016.
The problem is clear, just a click away. We encourage all affected agencies and organizations to forge past the denial that often develops around this subject and work together to develop a plan and take action.
The lengthy article was written by Kurt Eichenwald and was the result of an interview and correspondence with David Kwiatkowski, the radiologic technician who was sentenced to 39 years in prison after infecting patients with hepatitis C through unsafe injection practices. Kwiatkowski, who was infected with hepatitis C, stole injectable pain medications from the hospital where he was working and injected himself. He changed the needle, rinsed the syringe with water, refilled the syringe with saline and put these syringes back on the medication cart for use with patients. In this way, at least 45 patients in seven states were infected with hepatitis C. One patient has died from the infection.
Regrettably, this scenario is not unusual in the United States. The CDC estimates that 30,000 people may have been exposed to hepatitis C over the past decade by infected hospital employees who have used narcotics intended for patients. Federal researchers estimate that 100,000 healthcare workers in the United States are addicts and their theft of narcotics from patients is believed to be widespread. As many as 379,000 health care workers in the United States are addicted to drugs or alcohol, according to New Jersey pharmacist Mitch Sobel, who delivered this information at a recent New Jersey Department of Health meeting.
Getting back to the excellent Eichenwald article, what is unusual is that Kwiatkowski apologized…and desribed how he diverted drugs so that we can correct the healthcare delivery system to prevent harm to the public.
Since he is not eligible for parole, Kwiatkowski has nothing to gain from his disclosures. In fact, he and prison officials fear the article might anger other inmates and place him in danger.
As one who contracted hepatitis C through unsafe injection practices, i want to commend Mr Kwiatkowski for apologizing and sharing his story. It is so meaningful to victims when there is an apology; I still yearn for the gift of this simple, but profound gesture of respect. It is very difficult to fully heal from harm of this magnitude without an apology–it is as if something is missing, and closure is impossible.
Kwiatkowski not only apologized, but gave us a clear picture of how diversion takes place in hospitals. This important “insider” knowledge–not unlike when casinos ask cheaters to help them catch other cheaters–will help us make the changes that are long overdue. As we reported in a previous blog, HONOReform is helping to head efforts at a national level to help prevent drug diversion. We encourage all stakeholders to join us.
In the Newsweek article, Kwiatkoski said he is “haunted by the knowledge that he hurt so many people and believes he needs to make amends by revealing the scope and methods of this medical crime that endangers un unknowing public. “
Somebody has to tell how it’s done, how easy it is and how the structure of the hospitals isn’t any good to stop it,’ he says of drug diversion.”
Examining all ways to prevent drug diversion has never been more important. Patients throughout the country are harmed, and there is no national system in place to stop diverters. From just one patient affected by unsafe injection practices, thank you, David Kwiatkowski, for your candor. We need you and others continue to tell us how to fix the system that is so easy to violate.
A huge thank you to the wonderful epidemiologists at both the Colorado Department of Public Health and Environment (CDPHE), Division of Disease Control and at the Centers for Disease Control and Prevention (CDC), Viral Hepatitis Division for their major article published this month in the American Journal of Infection Control. Their article, “Outbreak of hepatitis C virus infection associated with narcotics diversion by an hepatitis C virus-infected surgical technician,” outlines the happenings surrounding the Hepatitis C outbreak in Colorado in 2009. Their in-depth study of this situation brilliantly highlights the need for better health surveillance in identifying such outbreaks and the diversion which causes them. Read more
Welcome back to the HONOReform blog, aka “Survivor Stories,” for our second full year of publication. We thank everyone who has had a role in making our blog a growing success—contributors and readers and everyone who has suggested to friends that they should check out our blog and pass it on to others.
And we encourage you to please continue to support our efforts.
Here at HONOReform, community-building is a key to emphasizing safe injection practices and doing all we can to educate the public and reeducate providers on the absolute necessity of injection safety. Read more
If you are a regular member to this blog you will have heard me say these things before, so I apologize for the repetition, but it appears I may not be saying it loud enough. So I am thankful to have the support of fellow patient safety advocates, healthcare workers who understand the broken system as well as a series of talented reporters to help articulate the point.
Our healthcare system is broken, let me say that again, it is broken and not the way the majority of Americans might think after reading that statement. It isn’t about the Affordable Care Act, in fact, just the opposite. It is underneath the polished floors and inside the magnificent facilities. It is behind the scenes, what happens when most people are not watching. Read more
In this blog, HONOReform executive director Steve Langan, included in the photo with Governor Hassan, thanks colleagues in New Hampshire for two new important laws–and he includes a recent AP story.
Congratulations and many thanks to our colleagues in New Hampshire, many of whom are included in the August 6 AP article by Rik Stevens, which is appended below, for their determination to create and pass legislation in New Hampshire that will help protect patients there.
“We believe these two new measures will be of great benefit in insuring the safety of the patients who are receiving care in our hospitals and also in insuring the integrity of the healthcare delivery system,” said Steve Ahnen, president of the New Hampshire Hospital Association. “These laws are an important step forward in preventing these horrific acts from occurring again in New Hampshire and, potentially serving as a model for the rest of the nation.” Read more